Emergency Management of the Hi-Tech Patient in Acute and Critical Care

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Sarah Fesnak1,2, Xenia Morgan3, and Kimberly Windt3

1 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

2 Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA

3 Hemodialysis Unit, Division of Nephrology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA

Hemodialysis is a procedure to regulate fluid status and remove waste products and/or toxic substances from a patient's blood. Vascular access allows a patient's blood to be circulated extracorporeally through a dialysis machine, where it filters past a semipermeable membrane in contact with a washing solution (diasylate). Fluid and solutes are removed via diffusion, osmosis, and convection. Hemodialysis is one of three forms of renal replacement therapy (the others are peritoneal dialysis and renal transplant) available to patients with advanced renal failure. Patients may require hemodialysis on a long‐ or short‐term basis, depending on their underlying disease process and potential for transplant, with many patients undergoing years of dialysis. Nearly 300 000 patients in the US have end‐stage renal disease, and more than 60% of these undergo hemodialysis. The vast majority of these patients are adults, with fewer than 1% of hemodialysis patients under age 20 years. In both pediatric and adult patients, however, complications of vascular access remain a significant source of morbidity and mortality.

All forms of vascular access in hemodialysis allow blood to be pumped from the patient through the dialysis machine and back into the patient in a closed circuit. This circulation requires large‐caliber access for rapid circulation of patient's blood volume. There are several options for short‐ and long‐term vascular access in patients requiring hemodialysis.

These are large‐bore double lumen central venous catheters. Benefits of this type of access are that it can be placed rapidly and used immediately after placement and does not require any additional needle sticks for use. Drawbacks of this form of access include the risk of infection, potential for the catheter to become dislodged or removed inadvertently, and long‐term risk of vascular stenosis.

Nontunneled hemodialysis catheter: This is a short‐term form of access that can be placed emergently for acute use or to bridge to a longer‐term access option. It is typically placed in the internal jugular (<3 weeks) or femoral veins (<5 days) and then stitched into place.

Tunneled hemodialysis catheter: This is a long‐term tunneled and cuffed central venous catheter, typically placed in the right internal jugular vein, but may be placed femorally. It may be kept in place for years ( Figure 6.1).

These forms of access are surgically created anastomoses of the arterial and venous system used for hemodialysis. Venipuncture is used to access the anastomosis at each dialysis session. Benefits of these forms of access are decreased risk of infection as compared with central venous catheters and long use life. Note that the risk of infection remains higher in graft. Drawbacks include potential for thrombosis at the anastomosis, delay between placement and maturation/use, need to use needle sticks to access at each use, and potential cosmetic issues.